Basic Information
| Provider Information | |||||||||
| NPI: | 1073623666 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GJERDE | ||||||||
| FirstName: | PAMELA | ||||||||
| MiddleName: | ELENE | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6308 DRUID HILLS RESERVE DR NE | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303292056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6783713688 | ||||||||
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| Practice Location | |||||||||
| Address1: | 57 EXECUTIVE PARK SOUTH NE | ||||||||
| Address2: | STE 190 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303292288 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047786390 | ||||||||
| FaxNumber: | 4047786340 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | PT008073 | 01 | GA | LICENSE # | OTHER |